Thinking about drug law reform: Some
political dynamics of medicalization

Subtitle

Introduction

Many people believe that medicalization offers the most
reasonable approach to drug policy because it promises a dignified solution
to the conflicting goals of prohibition and humane treatment of addicts[1].The
medicalization model, by encompassing in the medical domain some phenomenon
or problem, allows medical considerations to be decisive in the interpretation
of that problem and in the choice of measures to resolve the situation.
With respect to drug use, medicalization can have a broad range of meanings
and consequences. When it means providing normal, good quality medical
care to drug addicts, including the prescription of illicit drugs, it
should be applauded as a positive development[2].

However, medicalization also may define regular, frequent drug use as
a mental disorder; designate abstinence as the only acceptable treatment
outcome; and/or recommend compulsory treatment for all users of illegal
drugs, be they dependent or casual users. The latter three versions of
medicalization demonstrate that, while the medicalization approach for
drug policy seems more humane than repression of drug use, it risks becoming
a form of repression itself.

One reason medicalization often is hailed as a more humane approach to
drug policy than reliance upon the criminal justice system alone is because
of the expectation that in the medical model, addiction no longer will
be stigmatizing because it is considered a disease, and, hence, addicts
no longer will be accused of being the cause of their problems. Another
reason is that it still seems impossible to promote serious discussion
of the more radical approach of repealing drug prohibition and creating
a set of legal regulations for the different groups of substances. Therefore,
some proponents of legal regulation hope that medicalization may be an
instrument in the transition to a legalized system, while other "legalizers"
accept medicalization as the second-best alternative.[3]

On the other end of the political spectrum, some hard-core prohibitionists
expect medicalization to leave punitive repression in place. One example
of the rhetorical excesses to which this application of the medicalization
paradigm can be taken is drug czar General McCaffrey's benevolently telling
the American people that the war on drugs metaphor really is not appropriate
(shortly before expanding the drug war in Colombia) and that fighting
drug addiction can better be compared to fighting cancer.[4]What
does this medical analogy mean? In surgery, cancers have to be eradicated,
often along with a wide margin of healthy tissue, for safety. Further,
chemotherapy kills many healthy cells. So here, the medicalization paradigm
is used as a legitimization of collateral damage-no different than in
a war. It provides the rhetorical cover for continuing the current repressive
policies in the war on drugs.

On the whole, criticism of the medicalization approach-particularly from
drug law reformers-is not welcome in the current climate of support for
a policy of repression. This lack of receptivity to such criticism exists
both among policy makers and the public at large. Some drug law reformers
have advanced arguments that drug addiction is not a disease which requires
a "cure," but a complex phenomenon, resulting from individual desires,
and for which one must accept personal responsibility.[5]This
seems to have alienated the public, thus diminishing the reformers' chances
of progress through building public support.

Being aware of this difficulty, and acknowledging possible positive aspects
of medicalization, I begin this essay by offering a few critical words
on the position of the medical profession in drug policy.[6]Then,
I will attempt to stimulate the drug policy debate by outlining certain
negative political ramifications and social consequences of an abstinence-directed
medicalization policy. I will argue that:

Making addicts responsible for their own cure and failure of treatment
will result in more (coerced) treatment.

An obsessive fear of loss of control leads to a mistaken conception
of drug dependence and to a failure to distinguish between controlled
and problematic drug use.

There is a hidden link between medicalization and racial discrimination.

Medicalization creates a new elite class that benefits from drug prohibition
and is capable of creating new "patients."

The position of the medical profession in drug policy

Doctors have both the responsibility for the treatment
of people with dependency problems and the monopoly in prescribing some
otherwise illicit drugs. Furthermore, doctors occupy a unique dual position
in the drug policy debate: an official one, as individual medical experts
and as professionals; and an unofficial one, as physicians to and friends
of influential people. Although presidents and prime ministers typically
are not experts on drugs, they do not accept automatically the recommendations
of expert committees. Our leaders understand that experts can be found
to support any number of opinions and viewpoints. For their own comfort,
leaders informally may consult their private physicians, whose opinions
they have learned to trust, and ask for their thoughts on the legalization
of drugs. Unfortunately, most doctors suffer from the Clinician's Illusion.[7]
Therefore, those doctors' answers are more likely to be, "Oh, no,
that would be too risky" rather than, "Yes, that will have a
beneficial effect on public health, not to mention the other areas that
you know more about."

Some doctors do not believe that their medical responsibility is at stake
in such a situation, and that a formal advisory function should accompany
their medical expertise. This attitude may result in the situation in
which doctors would have to collaborate in coerced treatment-with poor
results-but not feel free to say that the medical argument for prohibition
fails. One could call this the "half-medicalization" scenario.
These doctors may assume that the decision to prohibit drugs is a political
one, and the status of being a doctor does not render their opinion on
national drug policy to be any more important than the opinions of other
citizens. Nevertheless, every official text on drug policy contains medical
arguments and health considerations that are advanced as important, if
not essential, reasons for prohibition. Doctors, therefore, are in a unique
position to understand and explain that many of the pro-repression health
arguments, such as the risks of toxicity and addiction, are abused by
proponents of prohibition. Doctors, both individually and collectively,
should educate the public and the policymakers that there are no sufficient
reasons to treat illicit drugs so differently from alcohol and cigarettes,
and that health and medical arguments actually plead for legal regulation.

The crucial importance of doctors' opinions on the subject of drugs was
underlined at the Eighth International Conference on the Reduction of
Drug-Related Harm, March 1997 in Paris.[8]
A hot topic at the conference was the resistance by French medical specialists,
especially psychiatrists, to the introduction of harm reduction methods.[9]
At the closing session of the conference, three French ex-ministers of
health, Barzach, Kouchner, and Veil, accused the medical profession of
systematically sabotaging necessary reforms.[10]
Simone Veil even compared the potential role of doctors in the drug policy
debate to that played by doctors in reaction to the scandal of HIV-infected
transfusion blood, explaining that it had been general practitioners who
successfully initiated policy changes in France to promote greater safety.[11]The ex-ministers painted a picture of negligence,
abuse of power, self-interest and prejudice on the part of the medical
community with respect to the issue of drug policy. For example, the results
of the only French methadone project, the famous "25 places"[12]
in Paris, were kept secret, probably because they were positive and provided
support for continuing the project. Further, French psychiatrists who
were considered specialists on the subject of drug use have long claimed
that every addict should be treated and cured only psychotherapeutically.[13]
Indeed, methadone prescription was not considered a therapy. These specialists
expressed an unwillingness to explore literature from which they could
have learned about other developments in the field. Even when they did
peruse such studies, these specialists found excuses for rejecting the
articles' findings, such as the belief that foreign articles were not
reliable.

That doctors are publicly blamed by prominent politicians for the inferior
French drug policy and for their indirect involvement in hundreds of AIDS
and other drug-related deaths, provides a compelling reason for the profession
to reexamine its role in the drug policy debate. Doctors are blamed not
just for negligence, but also for their lack of knowledge and refusal
to learn from experiences in other countries. Even in the most favorable
analysis, prejudice accounted for this situation, because doctors confused
their personal, ideological opinions with professional knowledge.

The background of this confusion is that the medical attitude towards
drugs consists of a number of factors. I will discuss two of these factors.
First, there is the specific problem of the "Clinician's Illusion,[14]
an epidemiological phenomenon described by the American epidemiologists
Patricia and Jacob Cohen of which few doctors are aware. Doctors see users
only in treatment, or via the police and the judiciary, which means they
see a disproportionately large number of serious and chronic cases. Additionally,
in medical conditions with great variability in seriousness and duration,
such as drug dependence, doctors systematically underestimate the percentage
of cases that are lighter or have a shorter duration.[15]
In the case of drug use, the resulting "Illusion" would be a
mistaken belief that drug use is predominantly chronic and life-threatening.
Second, the war on drugs has created a media image of drug use that is
excessively negative, and doctors, no less than the general population,
are exposed to this distortion. The crucial point is that this distorted
image, which begins as a general phenomenon, is seemingly confirmed by
the impressions of doctors working under the influence of the Clinician's
Illusion.

Negative political and social aspects and consequences of an abstinence-directed
medicalization policy

1. Making Addicts Responsible For Their Own Cure

Because addiction is currently defined as a disease, addicts must be
"treated" (which in the United States is more often coercive
than voluntary), and "cured" (which is defined as remaining
abstinent). However, the well-known weakness of drug treatment is that
a large majority of patients will not reach this goal. This is also true
in the treatment of alcoholics and addicted cigarette smokers. Drug users
often will fail to fulfill their conditions of probation or requirements
set by a drug court, which results in incarceration or further coerced
treatment. So, while it may seem as if under medicalization addicts are
no longer accused of being the cause of their own problems (because addiction
is defined as a disease), what happens when treatment fails? A consequence
of the treatment paradigm, where abstinence is the dominant treatment
goal, is that addicts are held responsible for their own "cure."
When addicts are not cured on the orders of the state and the judicial
system, they will be punished, and put in prison anyway-just as they would
have been under a strict prohibition, or criminal justice approach. Forced
treatment may appear more humane than straight incarceration, but in practice,
for the majority of addicts who are not helped by treatment, or do not
wish to be completely abstinent, this scheme will mean long stretches
of lost freedom. This is because they suffer from a "disease"
for which other addicts-alcoholics or cigarette smokers-are not treated
involuntarily or punished, and, on top of that, for which treatment often
fails. Since their "disease" is proclaimed intolerable, coercing
them to be "cured" is considered ethical.

The argument is often advanced that without coercion there is insufficient
incentive to enter treatment and, within a medical paradigm, not wanting
to enter treatment is considered a symptom of the disease. However, this
is an inversion of reality. Since voluntary treatment is scarcely available
in the United States, for many people treatment is only accessible when
they are incarcerated.[16]

2. An Obsessive Fear Of Loss Of Control And Failure To Distinguish Between
Controlled And Problematic Drug Use

Inherent in the current medical conception of addiction in the United
States is the importance of external control over an individual's drug
use by the criminal justice system. This conception of addiction negates
controlled use, which may be defined as self-imposed, regular, moderate,
non-problematic use. Judging from movies and television, one gets the
impression that the American people's belief in strong external control
is linked to an obsessive fear of loss of personal control-to such a degree
that it has become impossible for many to believe that people can indeed
learn to use drugs moderately and responsibly. By extension, the negation
of controlled drug use would lead to the idea that, without external control,
there would not be many people other than alcoholics drinking alcohol.
This is at odds with reality. It is well known from experience in more
liberal countries and from historical, anthropological, and current epidemiological
research that without professional help and on their own, more addicts
learn to stop using drugs, or learn to use them in a controlled way that
conforms to the conventional roles of productive citizens and parents,
than do in treatment programs.[17]

In the United States, it is standard policy to call every form of use
of illegal drugs either "abuse" or "addiction." In
the United Kingdom, a similar ideology labels all drug use as "misuse."
This shows that the current repression model of drug policy is not directed
at problematic users or at addicts in general, but that it is aimed at
all users of illegal drugs. The failure to distinguish between recreational
and responsible drug use on the one hand, and problematic or "addictive"
use on the other, gives prohibitionists the power to exert control over
every user of illegal drugs, regardless of whether the use is moderate
or excessive and regardless of whether it needs to be treated. In this
respect, medicalization is different from criminal justice models only
in that physicians will be in control of the policy and enforcement.

3. The Hidden Link Between Medicalization And Racial Discrimination

The number of blacks and Latinos in detention in the United States is
disproportionately large,[18]
but not because blacks and Latinos use more drugs. They are poorer, their
use is more visible, and they are more often targeted by law enforcement.[19]
The term "disproportionately" is used somewhat euphemistically here. To
me, the number of minorities in detention is unbelievable.[20]
Every American who is confronted with this reality will need to find some
kind of justification for these racial disparities.

Today, genetic factors are cited to make it seem that there are sound
reasons for this horrible situation. Unfortunately, there are many historical
examples of medicalization providing the justification for sexist or racist
policies. Drug use is systematically associated with aggression and criminality.
The media has reported about genetic factors contributing to addiction,
aggression, and criminality. These reports often are accompanied by images
of minorities. This fallaciously implies that drug use is genetically
determined. It suggests that genetic traits leading to addiction, aggression,
and criminal behavior are more prevalent in some minorities than in whites,
and that this is why so many minorities are incarcerated for drug offenses.
This untruth perpetuates the idea that the U.S. drug problem is specific
to African-American and Latino communities, rather than that it is a general
social problem.

The contemporary popularity of genetic explanations for behavior has
prompted many medical experts to provide information and give their views
on various social problems. Medicalization should mean that doctors make
their views heard, individually and as a group. When the social problems
resulting from current drug policies are treated as personal medical problems,
doctors should not through their silence lend tacit support to the current
and fallacious genetic explanation for drug use or incarceration rates.

A significant portion of the U.S. population believes in the idea of
addiction as a disease in which one cannot sufficiently control oneself.
On the one hand, this leads to a hard approach towards drug addicts and
an acceptance of punishing them for their lack of personal control. On
the other hand, many people apply this concept to themselves in a remarkably
softened way. A function of this conception of addiction is that it diminishes
the burden of personal responsibility in our daily behavior. Of course,
it does not completely eliminate personal responsibility, but it diminishes
it to an important degree. This image of addiction, as a condition for
which one is not completely responsible, has a peculiar attraction. The
theme of addiction is often noticeable in ad campaigns for consumer goods.
The addiction concept is so banal that addiction becomes something from
which everyone suffers. This concept facilitates acceptance of one's weakness
as a consumer, but at the same time allows for the belief that one's addiction
is not as bad as that suffered by others. Mass consumption becomes an
inability to resist the desire to buy a product, such as a piece of chocolate
or a car, rather than a controllable urge. That is exactly what advertising
is about-getting people to allow themselves to buy a specific article,
which they want so badly, but do not really need.

5. Medicalization Creates A New Elite Class That Benefits From Drug
Prohibition And Is Capable Of Creating New "Patients"

The rising status and influence of addiction medicine and addiction psychiatry
provide for a new caste of professionals who profit from drug prohibition.
The addiction medical elite make believe that the status of addiction
as a brain disease is firmly established. In reality, the scientific discussion
on the nature of addiction is far from closed.[21]The
National Institute on Drug Abuse ("NIDA") (a remarkable name:
aren't they interested in drug use?) pays hundreds of millions
of dollars per year for the construction of the unwarranted dominance
of clinical biopsychopharmacological research.[22]

When the disease concept is not strictly reserved for medical conditions
but is expanded to regular drug use and to other socially unacceptable
behavior, repression and prohibition of deviant behaviors flourish. This
is not a new idea, but in thinking about drug users, habitually or ritually
called "abusers," it is generally not recognized that many regular
users of alcohol and cigarettes also would be viewed as addicts if the
substances they used were illegal. Because alcohol and cigarettes are
still legal, drinkers and smokers can function as normal citizens, and
the question of whether their pattern of usage should be called addiction
does not seriously arise for most of them.

Under current prohibition policies, medicalization creates its own patients.
Many drug users officially are considered and treated as addicts. However,
under a legal regulation regime, they generally would be viewed as regular,
heavy users, and not as addicts. There are at least two reasons for this
categorization: First, the most widely used psychiatric diagnostic system
is the American Psychiatric Association's Diagnostic and Statistical Manual
of Mental Disorders ("DSM").[23]This
system uses two criteria which are strongly context-dependent in the definition
of substance dependence, and as a result, many users of illicit drugs
will be included in this definition primarily because of the illegal status
of their drugs, not because of any physical or mental impairment.[24]
When doctors espouse the view that drug dependence is a disease, they
should at least point out to the general public that most drug users are
normal, healthy people and that, if addiction is a disease, it is a very
special kind of disease. Few diseases exist in which the patient can decide
to say, at almost any point during the course of the disease, "All
right, I am fed up with this disease. I am going to be cured from now
on." This does not fit the medical model. It can only be explained
by the combined influences of psychological, social, and biological factors
on drug users, and on the course and development of usage patterns. This
shows the necessity of applying the biopsychosocial model to drug dependence
discourse.

Second, the penal system, and especially the drug courts, refer large
numbers of users to treatment systems after an arrest for possession or
sales, not because of addictive behavior. To its discredit, the treatment
system in general accepts these "patients." Of course, under
prohibition, the "patients" also profit from this situation,
because it offers them a milder type of punishment than incarceration.

Conclusions

When drug prohibition and the abstinence paradigm are kept
in place, medicalization will mean even less voluntary and more coerced
treatment, which is ineffective for most people, and no freedom for recreational
or other forms of controlled drug use. The most important political consequence
of this kind of medicalization is that it allows for the continuation
of excessive control over all drug users by the criminal justice system.

The medical profession carries an important part of the responsibility
for not informing the general public about the effects of drugs and the
nature of drug use, and for keeping in place a system of drug prohibition
which has proved to be harmful to public health and especially to minorities.
Doctors should explain that drug prohibition lacks a scientific foundation
and that public health would be better served by legal regulation.

Addendum

All over the world, new repressive drug policy measures
with direct implications for public health, are introduced regularly without
any serious scientific evaluation. However, with respect to research on
harm reduction measures such as, for instance, the distribution of heroin,
there seems to be a general consensus that only one design can be applied,
the randomized controlled trial (RCT).

Randomized controlled trial inadequate for the development of drug policy

Whereas this design may be the preferred design for clinical
pharmaceutical research, it is of limited value in the effort to improve
drug policy and addiction care. The RCT is appropriate for the introduction
of new therapeutic substances, such as antidepressants and antipsychotics,
but heroin is not a new substance. And the addicts who are the subjects
of the research have been injecting or smoking heroin for years, and in
far worse circumstances. The difference is that the heroin is provided
on prescription, for a reasonable price, or even for free, so the addicts
are in a position to make changes in their lives. It is a social experiment
with a new care arrangement.

To indicate what this means, I would suggest that besides the usual kind
of control group, in this situation a second group of patients should
be selected who receive a monthly allowance equivalent to what the dope
would cost in that period. Maybe that group would do even better, and
in any case, this would provide us with useful information.

In prescribing heroin to heroin addicts, the randomized controlled trial
design creates a new and artificial pattern of usage - and what is subsequently
studied is this artificial pattern of use. As a consequence, the findings
are of limited value. Yet, despite this inadequate research design, some
positive results are noteworthy. Probably the most important result is
that the public-at-large and politicians in particular become accustomed
to the idea of providing heroin to addicts in poor physical and mental
condition, and learn that instead of dying, they become healthier and
function better.

The consumer perspective: stimulating internal control

Heroin distribution is usually considered within the paradigm
of treatment: frequent heroin use is seen as a manifestation of a chronic
or recurrent disorder. But why not look at it from the users´ perspective:
more or less frequent use, which is more or less problematic, with more
or less self-control. The central issue here is control. In any other
context, it would be only logical to take the consumers point of view
into consideration. What do we need to know from that perspective? What
we (should) want to know is how legal restrictions on the drug trade and
drug use can best be repealed or softened, and how personal, internal
control and informal and group norms can be stimulated to replace external
control. And for the design of new regulatory systems, we need to determine
the nature and minimum extent of external control needed in new situations.
The current heroin projects with their clinical-pharmaceutical approach
obviously cannot provide this information. For this purpose, research
is needed with an orientation toward social science rather than medical
and pharmaceutical paradigms.

Lack of scientific evaluation of the effects of UN drug conventions

Of course, new harm reduction methods should be judged
by the scientific community. But as a consequence of medicalization, inappropriate
demands are made for the research on heroin prescription and other alternative
methods, whereas no serious official scientific evaluation takes place
of the consequences of drug prohibition for public health. One of the
few scholarly evaluations of drug prohibition, Drug Prohibition And Public
Health by Ernest Drucker, convincingly demonstrates this policy's devastating
consequences for public health (Drug Prohibition and Public Health, Public
Health Reports, Jan.-Feb., 1999). At the United Nations Drug Summit in
June 1998, an evaluation of the last decade of international drug policy
was initially planned, but later dropped from the agenda. WHY should science
require far more stringent evidence for recommending the reversal of bad
drug policy than for supporting its continuation? This disparity between
the demands for scientific evaluation of repressive and of liberal policies
is unfounded and unacceptable.

Notes

* The author is psychiatrist at the
Department of Mental Health, Municipal Health Service of the City of Amsterdam,
in the Netherlands and member of the board of the Dutch Drug Policy Foundation.
E-mail: fpolak@knmg.nl (back)

Although I prefer other terms, such as frequent
users, problematic users, and compulsive users, I also use the word
"addicts" to indicate that I mean the same loosely defined group of
regular drug users.(back)

In 1994, the Stichting Drugsbeleid (Netherlands
Drug Policy Foundation) published a report on the need for legalization
which contained a proposal for the first phase of the transition to
legal regulation. This system was based on the combination of controlled
sales of "normal" doses of all presently illegal drugs to adults (the
report recommended that the age requirement should be the same as for
alcohol and cigarettes, which means sixteen or eighteen in most western
countries) with medical prescription of larger doses of these substances
to dependent people. Netherlands drug policy found., drug control through
legalization: a plan for regulation of the problem in the Netherlands
(Engl. translation 1996), http://www.drugtext.org/reports/ nlplan.(back)

This text is not a scientific article, but a medico-political
essay. There is little scientific evidence about many of the themes
upon which I touch. As a psychiatrist, I have seventeen years of experience
in general psychiatry in a system in which addicts were often shut out
and referred to the categorical field of addiction treatment, and ten
years of experience in addiction treatment in the public health system.
I have some experience in medical organizational politics and in lobbying
political parties. In this essay I did not try to pose as a scholar.
I thought that I should stay close to my core business in drug policy,
which is the link between psychiatry and medicine on the one hand, and
politics on the other. From that position I have developed a critical
view of what medicalization can do to alleviate drug problems.(back)

Id.; see also Freek Polak, The Medicalization
of (Problematic) Intoxicant Use and the Medical Provision of Psychoactive
Drugs, in De-Americanizing drug policy The search for alternatives
for failed repression (Lorenz Böllinger ed., 1994, 175-187).(back)

See Lorri Preston, New Treatments Further
Complicate AIDS in U.S. Prisons, AIDS Weekly plus, June 29, 1998
(discussing how prison inmates are likely to receive better treatment
for AIDS while incarcerated than upon release).(back)

Stanton Peele, Can Alcoholism and Other Drug
Addiction Problems Be Treated Away or Is the Current Treatment Binge
Doing More Harm Than Good?, 41 J. Of Psychoactive drugs 375 (1988).(back)

See Butterfield, supra note 18 (noting
that the incarceration rate for black men in their late twenties is
almost ten times the rate for white men).(back)

See Psychological theories of drinking
and alcoholism (Kenneth E Leonard & Howard T. Blane eds., 2d ed. 1999)
(mentioning a range of theories on alcohol and drug dependence, supported
by a steady stream of research that claims to increase the understanding
of mechanisms of addiction); see also Stanton Peele, Diseasing
of America (Jossey-Bass 1999) (1989) (criticizing the American treatment
system).(back)

in the Diagnostic and statistical manual of mental
disorders, three of seven criteria are needed for the "diagnosis"
of "Substance Dependence." Id. at 176-79. The DSM gives the
following formulations for criteria 5 and 6-criterion 5: "a great
deal of time is spent in activities necessary to obtain the substance
(e.g., visiting multiple doctors or driving long distances)" and
criterion 6: "important social, occupational, or recreational activities
are given up or reduced because of substance use." Id. at 178.
For the "diagnosis" of "Substance Abuse," one of
four criteria suffices. Criterion 3 is as follows: "recurrent substance-related
legal problems (e.g., arrests for substance-related disorderly conduct)."
Id. at 182.(back)